Provider Demographics
NPI:1508039819
Name:CASTILLO-NIEVES, EDGARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:
Last Name:CASTILLO-NIEVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDGARDO
Other - Middle Name:
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1530 LEE BLVD STE 1400
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4887
Mailing Address - Country:US
Mailing Address - Phone:239-368-7310
Mailing Address - Fax:239-368-7312
Practice Address - Street 1:1530 LEE BLVD
Practice Address - Street 2:SUITE 1600
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4893
Practice Address - Country:US
Practice Address - Phone:239-368-7310
Practice Address - Fax:239-368-7312
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26,410-R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112016700Medicaid